=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568890606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARILEE L.M. WASELL, PH.D. CLINICAL AND CONSULTING PSYCHOLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2013
-----------------------------------------------------
Last Update Date | 10/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3579 4TH AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-200-3658
-----------------------------------------------------
Fax | 619-717-8710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3579 4TH AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-200-3658
-----------------------------------------------------
Fax | 619-717-8710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARILEE LAYNE WASELL
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 619-200-3658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY20864
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------